19132A (16-11)

CLAIM FOR HEALTH CARE BENEFITS

C. P. 3950Lévis (Québec) G6V 8C6

GROUP INSURANCE - HEALTH CLAIMS

Page 1 of 2

IN ORDER FOR US TO PROCESS YOUR CLAIM, PLEASE ANSWER ALL QUESTIONS THAT APPLY TO YOUR SITUATION AND SIGN SECTION I.

Policy or group or contract no. Certificate no. Name of group or policyholder or employer

Member's last name and first name Sex Date of birth

Address - Number, street, apartment City Province Postal code

M FYYYY MM DD

A - IDENTIFICATION - MANDATORY SECTION This information can be found on your insurance certificate or payment card.

Ineligible expenses - I wish to use my Health Spending Account to cover the expenses that are not reimbursed under my group insurance plan.

Spouse's family coverage - I wish to use my Health Spending Account for myself and my dependent children to cover the expenses that are not reimbursed under my group insurance plan. I will not submit a claim to my spouse's insurer (coordination of benefits).

I do not wish to use my Health Spending Account.

D - HEALTH SPENDING ACCOUNT If you have this benefit, check the option you would like.

I confirm that I am eligible for a reimbursement of the indicated expenses under my Health Spending Account.I recognize that I am responsible for paying any taxes that may result from the reimbursement of these expenses and that, for tax or administrative purposes, my plan administrator may have access to a statement of expenses for which I claimed a reimbursement under my Health Spending Account.

C - COORDINATION OF BENEFITS

Last name and first name of person who has the other insurance coverage Sex Date of birth

Name of insurer Period of coverage If the other insurer is Desjardins Insurance:

Type of benefits: Drugs Dental care Medical and paramedical care Vision care TravelType of coverage: Individual Couple Single-parent FamilyLast name and first name of the dependents covered under this other insurance coverage

From To

M F

Desjardins Other Insurance Contract no.: Certificate no.:

YYYY MM DD

YYYY MM DD YYYY MM DD

If you are covered by more than one insurance plan, the coordination of benefits may entitle you to a reimbursement of up to 100% of your eligible expenses.HOW TO SUBMIT A CLAIM WHEN THERE ARE TWO INSURERS:1. The person who has the other insurance coverage must submit a claim to their own insurer first and then provide Desjardins Financial Security Life Assur-

ance Company (DFS), hereinafter Desjardins Insurance, with detailed information about the benefits paid (information found on the explanation of benefits), as well as copies of any receipts.

2. Claims for dependent children must first be submitted under the plan of the parent whose birthday (month and day) comes first in the calendar year.

B - DIRECT DEPOSIT SERVICE

Transit/branch no. Institution no. Account no.

Your email address (mandatory)

Attach a void cheque or provide your bank information below to sign up for direct deposit.

Once registered, your reimbursements for healthcare services will be deposited into this bank account. A notification email will be sent once your claims have been processed, and the explanation of benefits will be posted online rather than mailed. You must be registered on the secure site to consult your explanation of benefits. To register, go to desjardinslifeinsurance.com/planmember.Desjardins Insurance is not responsible for the accuracy of the banking information you enter and for verifying that the due amounts are deposited into your account.

üClaims processed within 2 business days?

Online and mobile services Direct depositVisit desjardinslifeinsurance.com/planmember to find out more.

ü

Desjardins Insurance life health retirement logo

Your claims can be processed within 2 working days. To find out more about our online and mobile services and the direct deposit service, please visit desjardins life insurance.com/planmember.

Picture of a avoid cheque.

Page 2 of 2Please send to: Desjardins Insurance, C. P. 3950, Lévis (Québec) G6V 8C6

Attach your original receipts to this form and keep copies for your files. The original copies will not be returned. Your explanation of benefits and the copies of your receipts are sufficient for income tax and coordination of benefit purposes.Claims MUST BE submitted no later than twelve months after expenses are incurred.

Is the claim the result of:• Work injury? Yes No • Motor vehicle accident? Yes No

Name of injured person: Date of accident:

F - INFORMATION ABOUT THE CLAIM

YYYY MM DD

G - OUT-OF-PROVINCE EXPENSES

All the information I have provided on the claim form is accurate and complete. I acknowledge having read the Personal Information Management section. I authorize Desjardins Insurance, strictly for the purposes of managing my file and settling this claim to:

a) collect from any person or legal entity, or from any public or parapublic organization, only the information deemed necessary to manage my file. The non-ex-haustive list of sources from which information may be collected includes health care professionals or facilities, insurance companies;

b) communicate to the said persons or organizations only the personal information about me that is deemed necessary for the purposes of my file;c) when necessary use the personal information it may have about me in existing files that are now closed.

This authorization is also valid for the collection, use and communication of personal information concerning my dependents, insofar as applicable to the claim. A photocopy of this authorization is as valid as the original.

Signature of the member Date

( ) - ( ) -

I - DECLARATION AND AUTHORIZATION FOR THE COLLECTION AND COMMUNICATION OF PERSONAL INFORMATION

H - PERSONAL INFORMATION MANAGEMENTDesjardins Insurance handles the personal information it has on you in a confidential manner. Desjardins Insurance keeps this information on file so that you may benefit from group insurance services offered by the Company. This information is consulted solely by Desjardins Insurance employees who need to do so in the course of their work. Desjardins Insurance may compile anonymized personal information for statistical and informational purposes. Desjardins Insur-ance may also communicate with plan members to provide them with optimal health management. You have the right to consult your file. You may also have information corrected if you demonstrate that it is inaccurate, incomplete, ambiguous or not useful. To do so, you must send a written request to the following address: Privacy Officer, Desjardins Insurance, 200, rue des Commandeurs, Lévis, Québec, G6V 6R2. Desjardins Insurance may use the client list to offer its cli-ents an insurance product following the termination of their group insurance. If you do not wish to receive these offers, you may have your name removed from the list. To do so, you must send a written request to the Privacy Officer at Desjardins Insurance.

I confirm that the persons designated below fit the definition of spouse and depend-ent child as specified in the contract under which this claim has been submitted.Use one line per person.

CHILDREN AGED 18 AND OVER OR 21 AND OVER (depending on the policy)If your child has a functional impairment, please provide us with a

medical certificate confirming your child's disability.

E - INFORMATION ABOUT DEPENDENTS For the period in which expenses were incurred.

Relation Sex Date of birth Full-time student or hasa functional impairment

Name of educationalinstitution attended

M F

M F

M F

Spouse Child

Spouse Child

Spouse Child

YYYY MM DD

Last name and first name

Start date of cohabitation:

Child born Noof this union? YesOR

YYYY MM DD Date of marriage:

Date of birth:

YYYY MM DD YYYY MM DD

YYYY MM DD

YYYY MM DD

YYYY MM DD F. time Student Funct. Imp.

From ToYYYY MM DD

F. time Student Funct. Imp.

From To F. time Student Funct. Imp.

From To

YYYY MM DD YYYY MM DD

YYYY MM DD YYYY MM DD

g

Length of trip: From: To: Destination: Amount claimed: $

Reason for trip: Pleasure Business Receive care (please ensure that this type of trip is covered by your policy)

YYYY MM DD YYYY MM DD

IMPORTANT INFORMATION

In the case of a change of spouse, please indicate:

If yes: Please note that the claim must first be submitted under your provincial workers’ compensation plan or automobile insurance plan (if applicable in your province) before being submitted to your group plan.

Please include the original receipt itemizing all of your out-of-province expenses.

Note – This is not a travel insurance form. Visit desjardinslifeinsurance.com/travel-claim to find the correct form.

Telephone nos: Home: Office: Extension: